Fight or Flee, A Third Way

For several years, I served on our community hospital’s board. This not-for-profit hospital — like many such entities — is acutely aware of its bottom line. Predictably enough, the board agenda at the hospital often focused on maximizing the hospital’s market share and minimizing competition from other healthcare institutions.

The problem with this whole approach crystallized for me one day in a strategic planning meeting. Several of us were pressing the question of how the hospital could better address the healthcare needs of our town’s burgeoning Latino population and of low-income members of the community. In his attempt to justify the hospital’s focus on expanding profitability in other sectors of its program, the CEO put his point succinctly: “No margin, no mission.” I found myself blurting out in response, “No mission, no mission.”

Service to the community is repeatedly invoked as the hospital’s reason for being. But how can the hospital serve the community if it no longer exists?

The appeal to its mission often surfaces primarily as a justification for doing whatever it takes to make a profit because profitability assures the survival of the hospital. Institutional survival functions as a first-order imperative for the hospital administrator, and for many people who lead institutions. They start with survival and see it as the necessary condition for everything else.

There’s a certain commonsense logic in this approach.

The appeal to survival is so basic and instinctual for us creatures that we rarely challenge it or its underlying energy. As a result, we rarely question an analysis that asserts that survival is what’s at stake. But whenever I hear an appeal premised on the need for institutional survival, I see it as a red flag. Then I try to ask myself, “What course of action is being justified here, that would otherwise be indefensible? What is being advocated here that requires this visceral appeal?”

Appeals to survival grow out of and keep us stuck in a fight-or-flight mode. These appeals orient all our thinking to self-preservation rather than to vision.

Fight-or-flight reactions are rooted in fear, and they interfere with our ability to notice what is happening around us except as threats. We focus on the problems in our environment rather than on the opportunities and possibilities it presents.

Fear also stunts imagination; survival thinking is inimical to imaginative reflection. Fear keeps us from taking creative risks, even as we paradoxically take actions that risk our relationships and our whole reason for being.

When I see others caught up in the anxiety of survival, such thinking spurs me to ask, “If we follow this course, which is justified only in order to ensure our survival, will we survive to be the kind of organization we want to be?”

The challenge is to move away from letting survival dictate the framework for our discussion. Then we can ask the (in my judgment)more fundamental questions of identity and vision: “What are we about as an organization? What is our vision for who we want to be and what we want to do? How can we use our imaginations to find fitting and sustainable ways of being who we’re called to be and doing what we’re called to do?”

Of course, it’s about a zillion times easier to identify anxiety in others and see how much better they could be managing it. One major risk for administrators is an over-identification with the institutions we are charged with leading. It’s also tempting to see ourselves as indispensable, as critical to the organization’s future.

At one point in Maple City Health Care Center’s history, in the wake of an organizational crisis in which the board had asked the administrator to resign, the other physician on staff and I felt responsible for providing day-to-day management of operations. The board was struggling to understand its role in the wake of the administrator’s departure. It asserted its authority to oversee operations.

With no clear sense of how to oversee operations, the board seized on the course of designating one of its number to sign every check, to approve every expenditure and every course of action however trivial. The board excluded all staff members from its deliberations and gave us minimal information about their thinking and planning.

The other physician and I felt we had a much better sense than the board did of what was necessary for day-to-day operations. We felt responsible to keep things going, but we had been granted no formal authority to do so. The lack of trust between board and staff was making me feel crazy, and my anxiety mounted. I started feeling like the organization’s survival was at stake. This project, to which I had devoted ten years of my life, threatened to tank.

In times of crisis, my take-charge impulses kick in in a big way, and my urge to try to seize control was intense. Other staff members were ready to storm the next board meeting and challenge the board’s way of functioning. They toyed with the idea of calling a community meeting in order to unseat the board and start over. I considered resigning.

With lots of consultation and some non-anxious coaching, my anxiety calmed, and I decided to try to relinquish the impulse to fight or flee. I informed the board that I intended to refocus my energies on patient care and would be letting go of all responsibility, formal and informal, for keeping the center afloat. For three months, I would refocus my own vision in this way and allow the board to do its work. After three months, I would reevaluate my role and commitments.

I needed to face the possibility of finding another direction for my work, and I needed to give the organization the freedom to fold. In the space that these actions created, anxiety diminished, fears about survival retreated, and we were all eventually able to step back and rethink our roles and structures more constructively and productively.

Gradually relationships were rebuilt and trust was restored, as we found our imaginations free to refocus again on the health care center’s vision and reason for being.